Is a second transurethral resection necessary in T1 bladder cancer?
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Repeated transurethral resection of recurrent superficial bladder tumors--does it affect the spread and stage of the tumor?
OBJECTIVES: This prospective study was done to demonstrate the effect of repeated resection of superficial bladder tumors (TURT) on deep malignant cell infiltration in bladder wall. MATERIAL AND METHODS: Thirty-six patients underwent radical cystectomy for invasive bladder cancer, 16 patients originally had superficial cancer that became invasive after repeated TURT (group I) and the other 20 patients (group II) presented with invasive bladder cancer from the start. Each cystectomy specimen was subjected to a thorough histopathological study. RESULTS: There was a statistically significant difference in pattern of local spread of malignant cells between the two groups. Isolated clusters of malignant cells in-between normal bladder muscle fibers, isolated subserosal malignant deposits as well as cells reaching the adjacent cervix uteri were found only in group I. Intravesical pressure was measured in another 10 patients during TURT and was found to be high reaching up to 80 cm H2O. CONCLUSIONS: We conclude that some malignant cells penetrate through the denuded urothelium during TURT by the effect of high intravesical pressure. This may be responsible, among other factors, for tumor recurrence with deeper stages.
Adult↗
Intravesical adipose tissue: a quantitative study of its presence and location with implications for therapy and prognosis.
Accurate pathologic staging of carcinomas of the urinary bladder involves assessment of invasion by the tumor into the bladder wall and beyond into perivesical soft tissue. The presence of tumor within perivesical soft tissue implies pathologic stage pT3 (AJCC/UICC system, 1997). In traditional textbooks of histology, anatomy, pathology, and in the literature, other than a single case report and a brief reference in another paper, there is no information on the presence of adipose tissue in the lamina propria or muscularis propria of the urinary bladder. Nine hundred forty-three sections from 139 cystectomy specimens were evaluated for the presence, location, and quantity of adipose tissue within the lamina propria and muscularis propria. The histology of the perivesical soft tissues and the nature of its delineation from muscularis propria were also analyzed. Adipose tissue was seen within the lamina propria in 53% (74 of 139) of cystectomies and in 17.6% (166 of 943) of the examined sections. It was located predominantly in the deep lamina propria (at or below the muscularis mucosae) in 81.1% (60 of 74) of the cystectomies and in 91% (151 of 166) of the sections. Within the lamina propria it was predominantly seen as small localized aggregates in 92% (153 of 166) of sections. All cases showed adipose tissue within the muscularis propria. Adipose tissue was identified within the superficial (inner) muscularis propria in 54% (512 of 943) of sections and was predominantly in small aggregates in 80.5% (412 of 512) of sections. It was in moderate to abundant quantities within the deep (outer) muscularis propria in 60.7% (572 of 943) of sections. The perivesical soft tissue was almost exclusively composed of adipose tissue with variable vascularity. Delineation of the perivesical adipose tissue from the deep (outer) muscularis propria was typically indistinct because muscle bundles of the latter haphazardly merged with the perivesical adipose tissue. Based on these findings, we conclude that adipose tissue is frequently present in the lamina propria and muscularis propria of the urinary bladder wall, and is usually scant in the former location and frequently abundant in the latter. Awareness of the high frequency of adipose tissue within the urinary bladder wall has prognostic and therapeutic implications. In transurethral resection of bladder tumor (TURBT) specimens, misinterpretation of tumor infiltrating adipose tissue within lamina propria (pT1) as perivesical soft tissue involvement (pT3) may potentially result in unwarranted aggressive management. Substaging of muscle invasive tumors should be performed in cystectomy specimens only, because the junction of muscularis propria and the perivesical adipose tissue is typically ill-defined. Muscularis propria adipose tissue in TURBT specimens may be erroneously assumed to be perivesical adipose tissue, potentially leading to overstaging of the primary tumor.
Adipose Tissue↗
Adjuvant systemic chemotherapy after complete transurethral resection of superficially invasive bladder carcinoma (T1 G3-4 and T2 G2-4).
A prospective multicenter phase-two study was initiated in 1983 to evaluate the effect of systemic chemotherapy after complete resection of T1 G3-4 and T2 bladder carcinomas. Chemotherapy consisted of three cycles of cisplatin alone, a modified MVAC scheme or the combination of cisplatin and methotrexate. 52 patients entered the study. After a medium follow-up of 36 months 11 patients developed progression of the disease; cystectomy had been performed in 8 patients and 6 patients died due to progressive bladder carcinoma. These encouraging results should be the base for a randomized trial with the aim to improve survival and avoid cystectomy in selected patients with superficially invasive bladder cancer.
Antineoplastic Combined Chemotherapy Protocols↗
[Small cell neuroendocrine carcinoma of the urinary bladder: a case report].
A 60-year-old male was referred to our hospital with a complaint of asymptomatic gross hematuria. Cystoscopic examination revealed a non-papillary broad-based tumor on the posterior wall of the urinary bladder. Computed tomography revealed no evidence of metastases. Transurethral resection of bladder tumor (TUR-BT) was performed and muscle invasion was detected by histological examination of the specimen. Total cystectomy and ileal conduit formation were performed at the preoperative diagnosis of T2-3N0M0. Hematoxylin-eosin staining of the specimen revealed small cancer cells with hyperchromatic nucleus and scanty cytoplasm growing in the muscle layer of the urinary bladder and in the left obturator lymph nodes. Immunohistochemistry for neurospecific enolase showed diffuse staining in the cytoplasm of cancer cells, and ultrastructural study showed dense core granules. From these findings, the patient was diagnosed with small cell neuroendocrine carcinoma of the urinary bladder at the stage of pT3bpN1M0. Three courses of adjuvant chemotherapies with cis-platinum (CDDP) and etoposide were administered. The patient is still alive with no evidence of any recurrence at 22 months after the operation. This case suggests that treatment with combined total cystectomy and adjuvant CDDP and etoposide chemotherapies is effective against neuroendocrine carcinoma of the urinary bladder with regional lymph node metastases.
Antineoplastic Combined Chemotherapy Protocols↗
[A case of bladder tumor producing granulocyte-colony stimulation factor and parathyroid hormone-related protein].
A 68-year-old woman presented with urinary pain and frequency. Cystoscopy, intravenous pyelography and magnetic resonance imaging showed a huge bladder mass and hydronephrosis of the left kidney. Transurethral resection of bladder tumor (TUR-Bt) was done. Histopathological findings of TUR-biopsy was high grade transitional cell carcinoma. Post operatively, the laboratory examination showed marked leukocytosis with a maximum of 99,600/mm3 in the peripheral blood and a high level of granulocyte colony stimulating factor (G-CSF), 70 pg/ml in the serum (normal: less than 9.8 pg/ml). Serum calcium level increased gradually and parathyroid hormone-related protein (PTH-rP) revealed high, 8.4 pMol/l (normal: less than 0.6 pMol/l). The tumor cells were positive for G-CSF and PTH-rP immunohistochemical staining. She died of the disease 46 days after the operation. This is the third case of G-CSF and PTH-rP producing bladder tumor in the literature.
Aged↗
[Septic shock following intracavitary Bacillus Calmette-Guerin therapy for postcystectomy ureteral cancer].
A 72-year-old female patient was diagnosed as having a tumor in her bladder at the department of obstetrics and gynecology. Transurethral resection of bladder tumor was performed in November, 2002. Pathology showed transitional cell carcinoma (TCC), G2>G3, pT1. Chemotherapy consisting of methotrexate, adriamycin and cisplatin and bladder instillation of Bacillus Calmette-Guerin (BCG) was performed. Re-biopsy revealed transitional cell carcinoma, G2, carcinoma in situ of the bladder and she received radical cystectomy with ureterocutaneostomy in June, 2003. After the cystectomy, the left ureter showed signs of cancer so BCG was administered through the left ureterocutaneostomy. During the second instillation, she had a high temperature and also exhibited signs of chills with frequent shivering followed by dyspnea, severe hypotension and tachycardia. We started the patient on dopamine and norepinephrine drips to maintain blood pressure and then started isoniazide and meropenem for presumed septic shock. The next day, the patient continued to be febrile and her condition deteriorated. After she was given endotoxin absorption therapy, she regained normal blood pressure and her heart rate, but was still febrile. After 13 days, rifampicin, ethambutol, and pyrazinamide were administered and after 18 days predonisolone was begun. From that point the patient's general condition gradually improved.
Administration, Intravesical↗
[Metastatic small intestinal tumor associated with transitional cell carcinoma: a report of 2 cases and review of cases in Japan].
Transitional cell carcinoma (TCC) frequently metastasizes to lymph nodes, liver, lungs and bone. However, metastasis to the gastrointestinal tract is rare. We report two cases of bladder tumor which metastasized to the ileum. According to the literature, these are the 7th and 8th cases in Japan. Case 1: A 87-year-old man had a history of bladder tumor (TCC, grade 3, pT2bN0M0) and has transurethral resection of bladder tumor (TUR-BT) three times. Two months after the last TUR-BT, he was admitted with ileus. As computed tomography (CT) showed abdominal free air, our diagnosis was perforation of gastrointestinal tract. The patient received an operation which resected partial ileum. We found the elastic hard tumor in the ileum on the perforated lesion, which showed metastatic TCC in the ileum pathologicaly. Case 2 : A 53-year-old man visited our hospital with gross hematuria. Cystoscopy showed a non-papillary broad based tumor in the right wall of the bladder. CT showed a bladder tumor invaded into the prostate (pT4aN1M0), we performed total cyctectomy and ileal conduit after neo-adjuvant chemotherapy. During the operation, we found the tumor (2 cm in diameter) in the small intestine which was metastasized of bladder tumor.
Aged↗
Transurethral resection of prostate and bladder tumors.
Endoscopic surgery of the prostate and bladder can be accomplished safely, efficiently, and economically, using outpatient or abbreviated-stay procedures. Local anesthetics rather than more traditional spinal or general techniques may also be used. Guidelines and techniques are described.
Ambulatory Surgical Procedures↗
Fluorescence endoscopy with 5-aminolevulinic acid reduces early recurrence rate in superficial bladder cancer.
PURPOSE: Several investigators have demonstrated an approximately 20% higher tumor detection rate by 5-aminolevulinic acid (ALA) fluorescence endoscopy compared to standard white light cystoscopy, and suggested a reduction in tumor recurrences when fluorescence endoscopy was performed as standard procedure during transurethral resection. We test this hypothesis. MATERIALS AND METHODS: In a prospective randomized multicenter study 102 patients underwent transurethral resection of bladder tumor(s) either with white light or ALA fluorescence assisted endoscopy. A second look transurethral resection with ALA fluorescence endoscopy was performed 6 weeks after the initial operation. RESULTS: At second look transurethral resection tumor was detected in 20 of 51 patients (39%) in the white light group and in 8 of 51 (16%) in the ALA fluorescence endoscopy group. This difference was statistically significant (p = 0.005). CONCLUSIONS: ALA fluorescence endoscopy is an innocuous and inexpensive diagnostic procedure that significantly improves bladder tumor detection rates compared to standard white light endoscopy. In our controlled study ALA fluorescence endoscopy reduced the residual tumor detection rate at second look transurethral resection by 59%.
Adult↗
[Treatment of superficial transitional cell bladder carcinoma. Long-term results of trial comparing transurethral resection alone and adjuvant chemotherapy with Doxorubicin].
OBJECTIVE: We compared the efficacy of transurethral resection alone or transurethral resection followed by bladder instillations of Doxorubicin for 1 year in patients with superficial bladder carcinoma, and followed them long term for the incidence of recurrence and progression to muscle invasion. MATERIALS AND METHODS: Between December 1998 and December 2000 a total of 69 patients with superficial transitional cell carcinoma of bladder participated in this prospective study. Final analysis of treatment results included 64 patients. Doxorubicin was administered to 25 patients, 39 patients were treated only by TUR. Patients were followed by control cystoscopy. RESULTS: The mean follow-up was 22.95 months; SD 7.79. Mean time to first recurrence in Doxorubicin group was 14.14 months; SD 7.84, in TUR alone group - 7.61 months; SD 4.4; p>0.05. Disease free survival was significantly prolonged in Doxorubicin group; p<0.05. There are no significant difference to comparison recurrence rate and progression rate between two groups. CONCLUSIONS: In regard to time of first recurrence and disease free survival this study indicates that adjuvant chemotherapy with Doxorubicin is superior to transurethral resection alone. However, progression in stage or recurrence rate was not influenced by the treatment regimen.
Administration, Intravesical↗
Radiochemotherapy after transurethral resection is an effective treatment method in T1G3 bladder cancer.
AIM: Conservative therapy using deep transurethral resection (TUR) followed by radiochemotherapy is a novel treatment strategy in stage TI grade 3 (TIG3) transitional cell carcinoma (TCC) of the bladder. The aim of this study was to present our long-term results of radiochemotherapy in T1G3 TCC patients. MATERIALS AND METHODS: A total of 64 patients with TIG3 TCC of the bladder underwent a TUR and a subsequent radiochemotherapy protocol at our institution. Following TUR, a median dose of 55.8 (range; 45-69.4) Gy radiation therapy was applied to the bladder, and simultaneous chemotherapy was initiated using cisplatin, carboplatin and/or 5-fluorouracil. After completion of the protocol, response was evaluated by repeat TUR, and check cystoscopies were performed at regular intervals. Median patient age was 66 (range; 30-82) years and median follow-up was 43.2 (range; 6-127) months. RESULTS: Complete response was achieved in 55 (90.2%) patients. Of the complete responders, 7 patients experienced a superficial (Ta, T1) recurrence and 8 patients had progression. In 8 patients with refractory superficial and invasive relapses, a salvage cystectomy was mandated. The overall progression rate was 14%. The overall and disease-free survival rates were 76% and 93%, respectively at 5 years. During followup, 4 patients suffered from reduced bladder capacity, and 2 patients underwent cystectomy due to shrinking bladder. CONCLUSION: Combined multimodality therapy is a safe and curative treatment option for patients with T1G3 TCC of the bladder in the hands of dedicated multimodality teams. Therefore, it is reasonable to justify radiochemotherapy combined with TUR in the first-line treatment of T1G3 tumors.
Adult↗
Hemostaseological management of urological operations in patients taking aspirin using the Thrombostat 4000.
A clinical study was started in order to examine the suitability of the Thrombostat (in vitro bleeding test) (IVBT) as a diagnostic tool to prevent perioperative bleeding due to aspirin (ASA) and/or platelet function disorders of other origins. This report is based on preliminary data. Eighty three patients who had ingested ASA in the last two weeks and/or with a history of bleeding and/or documented hemorrhagic disorders requiring distinct urological operations, were included in the study. In all patients the IVBT with CaCl2, in addition to common coagulation tests, were performed. Thirteen patients stopped ASA ingestion until IVBT became normal and did not show any increased bleeding tendency. The residual patients were classified by the various operations. The following operation groups were formed: Male genitals (n = 11), inguinal/suprapubic operations (n = 7), transurethral tumor resections of the bladder (TURB) (n = 17), transurethral prostate resection (TURP) (n = 12), tumor nephrectomy (n = 8), radical prostatectomy (n = 9). Thirty six patients with a history of ASA use, but normal IVBT, served as control group (C). Thirty one patients with a history of ASA ingestion had normal in vivo bleeding times (BT) and abnormal IVBT with CaCl2 (A). Seven patients had a bleeding history and/or documented hemorrhagic disorders (B). None of the patients (A) with abnormal IVBT but normal BT displayed clinically relevant bleeding. However, the blood loss was somewhat higher compared to the controls (C), especially in patients with TURB and radical prostatectomy (not significant).(ABSTRACT TRUNCATED AT 250 WORDS)
Aspirin↗
[The significance of urine cytology three consecutive days after transurethral resection as a predictor of superficial bladder cancer recurrence].
To determine whether there was any correlation between recurrence of superficial bladder cancer and the results of urinary cytology examined for 3 consecutive days after transurethral resection of the bladder cancer (TURBT), we retrospectively studied 64 patients with newly diagnosed Ta/T1 transitional cell carcinoma (TCC) of the bladder who had previously undergone TURBT. Urine cytology samples were reported as negative (class I, II) or positive (class III, IV, V). We used the Kaplan-Meier method to calculate the non-recurrence rate, and Cox-proportional hazard models to determine the prognostic significance of clinical and pathological findings. If any sample among the three consecutive cytology examinations was positive, we defined the case as positive. After a mean follow up of 19.5 months, 22 cases (34.4%) demonstrated recurrence probabilities of 24.1% and 42.3%, at 12 and 24 months, respectively. Of the positive cytology group (n = 33), 15 patients (45.5%) had recurrent tumor, while in the negative group (n = 31), only 7 cases (22.6%) developed recurrence. Multivarite analysis demonstrated that tumor size (p = 0.0022, Hazard ratio 8.9316), result of urine cytology for three consecutive days after TUR (p = 0.0051, Hazard ratio 4.5728), and age (p = 0.0124, Hazard ratio 3.7652) were associated with tumor recurrence. We suggest that positive results on urinary cytology for three consecutive days after TUR are indicative for tumor recurrence.
Carcinoma, Transitional Cell↗
[Value of a second transurethral resection in the assessment and treatment of patients with bladder tumor].
OBJECTIVE: To analyse the value of a second transurethral resection, repeated within 3 to 6 weeks after the initial resection, in the treatment and the classification of patients with bladder tumour. MATERIAL AND METHODS: We analyse the results of 72 repeated transurethral resection in 23 (32%) patients with T1 G1-2 bladder tumor, 9 (12.5%) with T1 G3 tumor, 31 (43%) with T2a G2-3 tumor and 9 (12.5%) with T2b G2-3 tumor. The evaluated patients are not associated with CIS. RESULTS: Of all 23 T1 G1-2 tumors, 13 (57%) had residual Ta T1 tumor and 1 (4%) T2 tumor. In this group, the second resection changed the treatment in 1 (4%) patient. Of all 9 T1 G3 tumors, 4 (44%) had residual T1 tumor and 1 (11%) T2 tumor. In this group the second resection changed the treatment in 1 (11%) patient. Of all 31 T2a G2-3 tumors, 5 (16%) had residual T1 tumor, 4 (13%) T2 tumor and 6 (19%) T3-T4 tumor. In this group, the second resection changed the treatment in 10 (32%) patient. Of all 9 T2b G2-3 tumors, 2 (22%) had residual T1 tumor, 1 (11%) T2 tumor and 2 (22%) T3-T4 tumor. In this group, the second resection changed the treatment in 3 (33%) patients. CONCLUSIONS: In T1 G1-2 and T1 G3 tumors, a second transurethral resection detect residual tumor in 36% of patients and change the treatment in 6% of patients. In T2a-b tumors, a second transurethral resection detect residual tumor in 50% of patients and change the treatment in 33% of patients.
Adult↗
Endoscopic correction of vesicoureteral reflux by subureteric Teflon (polytetrafluoroethylene) injection: review of 6-year experience.
BACKGROUND: Endoscopic correction of vesicoureteral reflux (VUR) was first proposed in 1981 and the first series of patients treated by subureteric polytetrafluoroethylene paste injection (STING) was reported in 1984. Although many successful studies, primarily European, have been undertaken since then, this technique has recently been rejected in the United States. In this paper, we report our 6-year experience and discuss indications for this technique. PATIENTS AND METHODS: Since February 1990, we have used the STING technique to endoscopically correct VUR. In this analysis, 38 ureters in 24 patients (mean age, 47.3 years; range, 7 to 79 years), with at least 1 year of follow-up were included. RESULTS: The first injection resulted in disappearance of VUR in 34 ureters (89.5%). A second injection was done for 2 failed and 3 recurrent ureters during follow-up, resulting in disappearance of VUR in the 3 recurrent ureters. The final success rates were 100% for both primary VUR and secondary VUR due to neurogenic bladder, but only 55.6% (5/9) for secondary VUR following transurethral resection of bladder tumors. No postoperative early or delayed complications were noted in any case. CONCLUSION: The procedure is simple and effective for the treatment of all grades of VUR. However, the procedure should be performed after careful consideration of the indications, since theoretically the risk of distant migration of the paste cannot be ignored.
Adolescent↗
Recurrence pattern for superficial bladder cancer.
AIM: Patients with superficial bladder tumors sometimes have long recurrence-free intervals. We evaluated whether patients with long recurrence-free periods had subsequent recurrences. We also clarified how these patients should be followed. MATERIALS AND METHODS: We enrolled 244 patients with superficial bladder cancer (62 pTa and 182 pT1) treated by transurethral resection of bladder tumor (TURBT) and adjuvant chemotherapy with pirarubicin. Median follow up was 75.5 months. Patients were stratified by the length of their recurrence-free interval. RESULTS: Recurrences occurred in 124 patients (50.8%). Of 185 patients who did not have a recurrence for the first 3 years, subsequent recurrences occurred in 65 patients; in more than half the first recurrence developed after 5 years or more. Ta tumors had a low recurrence rate (14.5%) with the first recurrence often developing after a long recurrence-free period. Of 40 patients who remained recurrence-free for 3 years or more after at least one recurrence occurred, 16 patients (40%) had subsequent recurrences. Furthermore, most of these patients who remained free of recurrence for more than 5 years eventually had a recurrence. The overall progression rate was 15.6%, and this did not relate to the length of the recurrence-free interval. CONCLUSION: When patients did not have a recurrence for the first 3 years, tumors subsequently often recurred, even in pTa tumors. In patients with at least once recurrence, subsequent recurrences appear to occur irrespective of the length of the recurrence-free period. Thus, we recommend that all patients with superficial bladder tumors be followed for as long as possible.
Adult↗
Nephrogenic adenoma of the bladder: two case reports and literature review.
In the two cases we report here, tumors were diagnosed as nephrogenic adenoma by pathohistological examination. Case 1 was a 72-year-old female presenting with a bladder tumor 8 months after receiving ureteral tumor surgery. Transurethral resection of bladder tumor (TUR-Bt) was performed. Case 2 was a 57-year-old female who had received intravesical bacillus Calmette-Guérin (BCG) treatment 6 times after her fifth TUR-Bt. Two tumors were found by cystoscopy, and TUR-Bt was performed. There have been 39 cases of nephrogenic adenoma of the bladder reported in Japan; 21 were male and 18 female with a mean age of 56.5 years. The main complaint was hematuria, which was seen in 16 cases followed by pollakisuria in 6 cases. Nephrogenic adenoma occurred after surgery of the urinary tract in 16 cases, followed by urinary tract infection in 9 cases and intravesical BCG treatment in 6 cases. The ratio of cases occurring after intravesical BCG treatment has increased since BCG approval for bladder carcinoma treatment in December 1996 in Japan, and an increase in the number of cases is expected in the future.
Adenoma↗